Unit 3 Semester 2
A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication? a. "Antibiotics will decrease the pain at the site." b. "An antibiotic helps to kill the infection causing the inflammation." c. "An antibiotic inhibits cyclooxygenase, an enzyme in the body." d. "Antibiotics will reduce the patient's fever."
"An antibiotic helps to kill the infection causing the inflammation."
A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient? a. "Don't eat with the other students." b. "Avoid sharing razors and other personal items." c. "Have a complete blood count (CBC) checked monthly." d. "Disinfect showers and bathroom floors weekly after use."
"Avoid sharing razors and other personal items."
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? a. "Thinking about dying will not improve the course of AIDS." b. "Do you think that taking an antidepressant might be helpful?" c. "Can you tell me more about the thoughts that you are having?" d. "It is important to focus on the good things about your life now."
"Can you tell me more about the thoughts that you are having?"
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Clean drug injection equipment before each use." b. "Ask those who share equipment to be tested for HIV." c. "Consider participating in a needle-exchange program." d. "Avoid sexual intercourse when using injectable drugs."
"Consider participating in a needle-exchange program."
A client who has rheumatoid arthritis reports that pain with exercising has increased. Which suggestion would the nurse provide to the client to decrease pain? 1 "For morning stiffness, take a tub bath rather than a hot shower." 2 "Apply ice directly to the involved joint for 20 minutes at a time." 3 "Decrease the number of repetitions of the exercises." 4 "Stop exercising for a day."
"Decrease the number of repetitions of the exercises."
A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a. "The coating on these medications is irritating to my intestines." b. "I need a more immediate response from my medications than can be obtained from enteric coated medications." c. "Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." d. "I don't need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks."
"Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue."
Which statement indicates a client understands transmission of the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. 1 "I can contract HIV by participating in oral sex." 2 "I can contract HIV by eating from used utensils." 3 "HIV is contracted by using contaminated needles." 4 "I can contract HIV by using the bathroom of a person who is HIV positive." 5 "Babies can contract HIV because of contact with maternal blood during birth."
"I can contract HIV by participating in oral sex." "HIV is contracted by using contaminated needles." "Babies can contract HIV because of contact with maternal blood during birth."
An 18-month-old child is seen in the clinic with AOM. Trimethoprim-sulfamethoxazole (Bactrim) is prescribed. Which statement made by the parent indicates a correct understanding of the instructions? a. "I should administer all the prescribed medication." b. "I should continue medication until the symptoms subside." c. "I will immediately stop giving medication if I notice a change in hearing." d. "I will stop giving medication if fever is still present in 24 hours."
"I should administer all the prescribed medication."
A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. "I will apply the eardrops to the cotton wick in the ear canal." b. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c. "I will clean the ear canal daily with a cotton-tipped applicator." d. "I can use warm compresses to the outside of the ear for comfort."
"I will clean the ear canal daily with a cotton-tipped applicator."
The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-yr-old female patient with cystitis when the patient states which of the following? a. "I can use vaginal antiseptic sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."
"I will empty my bladder every 3 to 4 hours during the day."
Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "The medication will be tapered if I need surgery." b. "I will need to use a sunscreen when I am outdoors." c. "I will need to avoid contact with people who are sick." d. "The medication prevents the infections that cause diarrhea."
"I will need to use a sunscreen when I am outdoors."
After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can exercise every day to help maintain joint motion." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."
"I will take 1 g of acetaminophen (Tylenol) every 4 hours."
Trimethoprim/sulfamethoxazole is prescribed for a child with a urinary tract infection. Which statement by the parent indicates the nurse's instructions about administration have been understood? 1 "Mealtime is a good time to give the medication." 2 "I'll make sure to give each pill with 6 to 8 oz of fluid." 3 "It must be taken with orange juice to ensure acidity of urine." 4 "The medication has to be taken every 4 hours to maintain a blood level."
"I'll make sure to give each pill with 6 to 8 oz of fluid."
A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse's best response? a. "Use ice only when the ankle hurts." b. "Ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days." c. "Wrap an ice pack around the injured ankle for the next 24 to 48 hours." d. "Ice is not recommended for use on the sprain because it would inhibit the inflammatory response."
"Ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days."
A nurse is teaching a group of business people about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following? a. "When traveling outside of the country, I need to be sure that I receive appropriate vaccinations." b. "Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance." c. "If I don't feel sick, then I don't have to worry about transmitted diseases." d. "I need to be sure to have good hygiene practices when traveling in crowded planes and trains."
"If I don't feel sick, then I don't have to worry about transmitted diseases."
The nurse is caring for a client who is to receive a blood transfusion. How will the nurse respond when the client expresses fear that acquired immunodeficiency syndrome (AIDS) may be acquired as a result of the blood transfusion? 1 "The blood is treated with radiation to kill the virus." 2 "The ability to directly identify human immunodeficiency virus [HIV] has eliminated this concern." 3 "Consideration should be given to donating your own blood for transfusion." 4 "Screening for the human immunodeficiency virus [HIV] antibodies has minimized this risk."
"Screening for the human immunodeficiency virus [HIV] antibodies has minimized this risk."
While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? a. "My body will treat the new kidney like my original kidney." b. "I will have to make sure that I avoid being around people." c. "The medications that I take will help prevent my body from attacking my new kidney." d. "My body will only have a problem with my new kidney if the donor is not directly related to me."
"The medications that I take will help prevent my body from attacking my new kidney."
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient will develop symptomatic HIV infection within 1 year." b. "The patient meets the criteria for a diagnosis of acute HIV infection." c. "The patient will be diagnosed with asymptomatic chronic HIV infection." d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."
"The patient has developed acquired immunodeficiency syndrome (AIDS)."
Which statement by the nurse explains the reason clients prescribed corticosteroid therapy for a chronic health problem develop frequent infections? 1 "They affect antigen-antibody immunity." 2 "They enhance the inflammatory process." 3 "The medication makes the white blood cells work harder." 4 "They increase the number of inflammatory chemicals in the blood."
"They affect antigen-antibody immunity."
The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient? a. "You will need to be retested in 2 weeks." b. "You do not need to fear infecting others." c. "Since you don't have symptoms and you have had a negative test, you do not have HIV)." d. "We won't know for years if you will develop acquired immunodeficiency syndrome (AIDS)."
"You will need to be retested in 2 weeks."
Which reported clinical manifestations would the nurse expect from a client with ulcerative colitis? Select all that apply. One, some, or all responses may be correct. 1 Fever 2 Diarrhea 3 Gain in weight 4 Spitting up blood 5 Abdominal cramps
1 Fever 2 Diarrhea 5 Abdominal cramps
Between which months of age would the measles vaccine be given according to the immunization schedule for babies? 1 2 and 5 2 6 and 8 3 9 and 11 4 12 and 15
12 and 15
Which conditions trigger humoral immunity? Select all that apply. One, some, or all responses may be correct. 1 Viral infection 2 Atopic diseases 3 Bacterial infection 4 Anaphylactic shock 5 Contact dermatitis
2 Atopic diseases 3 Bacterial infection 4 Anaphylactic shock
While caring for a client with a urinary tract infection, the nurse manager delegates the work of administering oral medications. Which delegatee would be appropriate for this task? Select all that apply. One, some, or all responses may be correct. 1 Registered nurse (RN) 2 Patient care associate (PCA) 3 Licensed practical nurse (LPN) 4 Licensed vocational nurse (LVN) 5 Unlicensed assistive personnel (UAP)
3 Licensed practical nurse (LPN) 4 Licensed vocational nurse (LVN)
Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 56-yr-old man who has a sedentary office job b. A 38-yr-old man who plays on a summer softball team c. A 56-yr-old woman who works on an automotive assembly line d. A 38-yr-old woman who is newly diagnosed with diabetes mellitus
A 56-yr-old woman who works on an automotive assembly line
Chronic otitis media with effusion (OME) is differentiated from acute otitis media (AOM) because it is usually characterized by: a. Fever as high as 40° C (104° F). b. Severe pain in the ear. c. Nausea and vomiting. d. A feeling of fullness in the ear.
A feeling of fullness in the ear.
Which finding would the nurse identify as normal inflammation versus an infection when assessing a client's wound that was sutured 72 hours ago? 1 Client report of increasing pain 2 A temperature of 101.6°F (38.6°C) 3 Small amounts of purulent drainage 4 A slight red border around the wound
A slight red border around the wound
Which condition is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T-cells? a. Wiskott-Aldrich syndrome b. Idiopathic thrombocytopenic purpura (ITP) c. Acquired immunodeficiency syndrome (AIDS) d. Severe combined immunodeficiency disease
Acquired immunodeficiency syndrome (AIDS)
Which type of immunity would a 4-year-old child develop during the course of an infection with varicella? 1 Active natural immunity 2 Active artificial immunity 3 Passive natural immunity 4 Passive artificial immunity
Active natural immunity
Which clinical manifestation indicates a need for the nurse to contact the health care provider to increase the intravenous fluid infusion for an older client with an infection? 1 Pruritus 2 Erythema 3 Acute confusion 4 General malaise
Acute confusion
Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? a. Age b. Lifestyle c. Symptoms d. Sexual orientation
Age
The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a. Suppressed immune response b. Hyperimmune response c. Allergic reaction d. Anaphylactic reaction
Anaphylactic reaction
Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation
Applying petroleum jelly to the lips
After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient.
Ask the patient about the concerns with stoma management.
A patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented? a. Assist the patient to soak in a 15-minute sitz bath. b. Restrict oral fluids to equal previous urine volume. c. Insert a straight urethral catheter and drain the bladder. d. Teach the patient how to do isometric perineal exercises.
Assist the patient to soak in a 15-minute sitz bath.
An infant's parents ask the nurse about preventing otitis media (OM). What should the nurse recommend? a. Avoid tobacco smoke. b. Use nasal decongestant. c. Avoid children with OM. d. Bottle-feed or breastfeed in supine position.
Avoid tobacco smoke.
Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours
BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours
The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population
Basic infection control techniques
Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Complaint of flank pain b. Blood pressure 90/48 mm Hg c. Cloudy and foul-smelling urine d. Temperature 100.1° F (57.8° C)
Blood pressure 90/48 mm Hg
Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)? a. Low urine output b. Bilateral flank pain c. Nausea and vomiting d. Burning on urination
Burning on urination
The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? a. Prednisone b. Adalimumab (Humira) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)
Capsaicin cream (Zostrix)
The school nurse is informed that a child with human immunodeficiency virus (HIV) will be attending school soon. Which is an important nursing intervention? a. Carefully follow universal precautions. b. Determine how the child became infected. c. Inform the parents of the other children. d. Reassure other children that they will not become infected.
Carefully follow universal precautions.
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the drugs should be taken.
Check the patient's class schedule to help decide when the drugs should be taken.
Which urine characteristic is consistent with a urinary tract infection? 1 Smoky 2 Cloudy 3 Orange-amber 4 Yellow-brown
Cloudy
A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Take this medication on an empty stomach. b. Take this medication with a full glass of water. c. You may have vivid and bizarre dreams as a side effect. d. Continue to use contraception while taking this medication.
Continue to use contraception while taking this medication.
The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient? a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain
Control inflammation
What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis? a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas d. Coping with stress and avoiding triggers
Coping with stress and avoiding triggers
What is used to treat moderate-to-severe inflammatory bowel disease? a. Antacids b. Antibiotics c. Corticosteroids d. Antidiarrheal medications
Corticosteroids
Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness
Costovertebral tenderness
A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours.
Crackles are heard halfway up the posterior chest
What is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus? a. Crohn's disease b. Ulcerative colitis c. Meckel's diverticulum d. Irritable bowel syndrome
Crohn's disease
A young child with human immunodeficiency virus is receiving several antiretroviral drugs. The purpose of these drugs is to: a. Cure the disease. b. Delay disease progression. c. Prevent spread of disease. d. Treat Pneumocystis jiroveci pneumonia.
Delay disease progression
When a client asks to be screened for human immunodeficiency virus (HIV) infection, which information will the nurse include in client teaching about the test? 1 Identifies the number of CD4 cells that are in the blood 2 Shows how much of the HIV virus is present in the blood 3 Takes several days for results to be complete and reported 4 Detects antibodies to HIV and may not detect acute infection
Detects antibodies to HIV and may not detect acute infection
Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden's nodules b. Discomfort with joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement
Discomfort with joint movement
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.
Discuss a change in antiretroviral therapy.
Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.
Drain and measure the output from the ostomy.
The nurse reviews the patient's complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response? a. Chronic b. Resolved c. Early stage acute d. Late stage acute
Early stage acute
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/μL and an undetectable viral load. What is the priority nursing intervention at this time? a. Encourage adequate nutrition, exercise, and sleep. b. Teach about the side effects of antiretroviral agents. c. Explain opportunistic infections and antibiotic prophylaxis. d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).
Encourage adequate nutrition, exercise, and sleep.
A common clinical manifestation of Hodgkin's disease is: a. Petechiae. b. Bone and joint pain. c. Painful, enlarged lymph nodes. d. Enlarged, firm, nontender lymph nodes.
Enlarged, firm, nontender lymph nodes.
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Explain to the patient that this is an expected finding. c. Request that an antibiotic be prescribed for the patient. d. Advise the patient that this indicates influenza infection.
Explain to the patient that this is an expected finding.
Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.
Fill the irrigation syringe with body-temperature solution.
To detect human immunodeficiency virus (HIV), most laboratory tests focus on the: a. virus. b. HIV antibodies. c. CD4 counts. d. CD8 counts.
HIV antibodies.
A client with jaundice reports fatigue, abdominal pain, loss of appetite, dark urine, nausea, and vomiting. Which pathogen would the nurse associate with this client's clinical manifestations? 1 Hepatitis C virus 2 Candida albicans 3 Varicella-zoster virus 4 Cryptosporidium muris
Hepatitis C virus
The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition? a. His immune system is functioning properly. b. He is properly vaccinated. c. He has an infection. d. The suppressor T-cells in his body are activated.
His immune system is functioning properly.
A mother diagnosed with acquired immunodeficiency syndrome (AIDS) states she has been caring for her baby even though she has not been feeling well. Which important information would the nurse determine regarding the care provided by the mother? 1 If she has ever kissed the baby and how 2 If the mother is breast-feeding her baby 3 When the baby last received antibiotics 4 How long she has been caring for the baby
If the mother is breast-feeding her baby
A construction worker sustains a puncture wound from a rusty nail and the last immunization for tetanus is unknown. The primary health care provider prescribes tetanus immune globulin. Which type of protection does this immunization offer? 1 Lifelong passive immunity 2 Long-lasting active protection 3 Stimulation of antibody production 4 Immediate passive short-term immunity
Immediate passive short-term immunity
Which effect would the nurse assess a teenager for if more than the recommended dose of oxymetazoline nasal spray is taken? 1 Nasal polyps 2 Ringing in the ears 3 Bleeding tendencies 4 Increased nasal congestion
Increased nasal congestion
A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.
Infuse metronidazole (Flagyl) 500 mg IV.
Which intervention would the nurse question when caring for a client who has tested positive for human immunodeficiency virus (HIV)? 1 Sonogram 2 Nonstress test 3 Sterile vaginal examination 4 Internal fetal scalp electrode
Internal fetal scalp electrode
Which statement is characteristic of acute otitis media (AOM)? a. The etiology is unknown. b. Permanent hearing loss often results. c. It can be treated by intramuscular antibiotics. d. It is treated with a broad range of antibiotics.
It is treated with a broad range of antibiotics.
During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Petroleum jelly works great when I use condoms." Which conclusion about the client's knowledge of condom use would the nurse draw from this statement? 1 An understanding of safer sex through proper use of condoms 2 An ability to assume self-responsibility and protection of others 3 Lack of knowledge related to correct condom application and use 4 Ignorance regarding transmission of human immunodeficiency virus (HIV)
Lack of knowledge related to correct condom application and use
A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a. Urinary urgency b. Left-sided flank pain c. Intermittent hematuria d. Burning with urination
Left-sided flank pain
Which information will the nurse teach a patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is tolerated better than whole milk.
Live-culture yogurt is usually tolerated.
The nursery nurse should identify which newborn at significant risk for hypothermic alteration in thermoregulation? a. Large for gestational age b. Low birth weight c. Born at term d. Well nourished
Low birth weight
An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching? a. Many drugs interact with antiretroviral medications. b. HIV infections progress more rapidly in older adults. c. Less frequent CD4+ level monitoring is needed in older adults. d. Hospice care is available for patients with terminal HIV infection.
Many drugs interact with antiretroviral medications.
Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate six times daily. d. Increase dietary fiber intake.
Monitor stools for blood.
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).
Most infants born to HIV-positive mothers are not infected with the virus.
A diagnosis of myasthenia gravis is suspected for a client who sees the primary health care provider because of fatigue, double vision, and muscle weakness. Which information would the nurse expect the client to report in the health history? 1 Muscle weakness improving after a period of rest 2 Symptoms worse in the morning upon awakening 3 Intermittent periods of hyperactivity 4 Slow, insidious onset of muscle weakness
Muscle weakness improving after a period of rest
A client's laboratory report indicates severe neutropenia and thrombocytopenia. Which medication may have caused this condition? 1 Daclizumab 2 Cyclosporine 3 Methylprednisolone 4 Mycophenolate mofetil
Mycophenolate mofetil
Which patient exposure by the nurse is most likely to require post exposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick injury with a suture needle during a surgery b. Splash into the eyes while emptying a bedpan containing stool c. Needle stick with a needle and syringe used for a venipuncture d. Contamination of open skin lesions with patient vaginal secretions
Needle stick with a needle and syringe used for a venipuncture
A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about the temperature. What is the nurse's best response? a. Older people have a diminished ability to regulate body temperature because of active sweat glands. b. Older people have a diminished ability to regulate body temperature because of increased circulation. c. Older people have a diminished ability to regulate body temperature because of peripheral vasoconstriction. d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates.
Older people have a diminished ability to regulate body temperature because of slower metabolic rates.
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? a. Nystatin tablet b. Oral acyclovir (Zovirax) c. Oral saquinavir (Invirase) d. Aerosolized pentamidine (NebuPent)
Oral saquinavir (Invirase)
While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection? a. Bacterial b. Fungal c. Parasitic d. Viral
Parasitic
While teaching a new mother ways to decrease the risk of infection for the newborn, which type of immunity would the nurse explain was transferred to her baby through the placenta? 1 Active natural 2 Passive natural 3 Active artificial 4 Passive artificial
Passive natural
Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose rapid HIV-antibody test is positive b. Patient whose latest CD4+ count has dropped to 250/μL c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs
Patient who has had 10 liquid stools in the last 24 hours
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/μL c. HIV-positive patient with a CD4+ count of 160/μL who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count trajectory b. HIV genotype and phenotype c. Patient's tolerance for potential medication side effects d. Patient's ability to follow a complex medication regimen
Patient's ability to follow a complex medication regimen
What is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population? a. Perinatal transmission b. Sexual abuse c. Blood transfusions d. Poor hand washing
Perinatal transmission
Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine? a. Take phenazopyridine for at least 7 days. b. Phenazopyridine may cause photosensitivity c. Phenazopyridine may change the urine color d. Take phenazopyridine before sexual intercourse.
Phenazopyridine may change the urine color
During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes
Physical agility
The nurse is educating a client on the use of heat and cold for osteoarthritis (OA) pain. Which action by the client indicates the need for additional teaching? 1 Places ice pack on skin 2 Uses ice pack for 20 minutes 3 Applies lightweight heating pad 4 Tests water before getting into shower
Places ice pack on skin
The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element? a. Host b. Mode of transmission c. Portal of entry d. Reservoir
Portal of entry
A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.
Position patient with the knees flexed.
The nurse planning care for a patient with hypothermia should consider what similar exemplar? a. Heat exhaustion b. Heat stroke c. Infection d. Prematurity
Prematurity
The nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice. Which goal is the nurse trying to achieve with this suggestion? 1 Exert a bactericidal effect against the bacteria 2 Prevent bacterial attachment to the bladder wall 3 Improve glomerular filtration rate 4 Relieve the symptoms of dysuria
Prevent bacterial attachment to the bladder wall
The nurse is planning care for an adolescent with acquired immunodeficiency syndrome. The priority nursing goal is to: a. Prevent infection. b. Prevent secondary cancers. c. Restore immunologic defenses. d. Identify source of infection.
Prevent infection.
A regimen of rest, exercise, and physical therapy is prescribed for a client with rheumatoid arthritis. Which purpose of the regimen would the nurse teach to the client? 1 Treating the arthritic pain 2 Halting the inflammatory process 3 Preventing additional joint damage 4 Providing for the return of lost joint motion
Preventing additional joint damage
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions
Prevention of HIV transmission between sexual partners
An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a. Primary immunodeficiency b. Secondary immunodeficiency c. Cancer d. Autoimmunity
Primary immunodeficiency
What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation? a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor
Rectal thermometer
The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates which assessment finding? a. Decreased respirations b. Low pulse rate c. Red, sweaty skin d. Slow capillary refill
Red, sweaty skin
A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient how to reduce risky behaviors. b. Inform the patient about the available treatments. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to identify individuals who had intimate contact with the patient.
Remind the patient about the need to return for retesting to verify the results.
What is the priority nursing action for a patient suspected to be hypothermic? a. Assess vital signs. b. Hydrate with intravenous (IV) fluids. c. Provide a warm blanket. d. Remove wet clothes.
Remove wet clothes.
Which intervention is most important in preventing hospital-acquired catheter-associated urinary tract infections (CAUTIs)? 1 Removing the catheter 2 Keeping the drainage bag off of the floor 3 Washing hands before and after assessing the catheter 4 Cleansing the urinary meatus with soap and water daily
Removing the catheter
Which diagnostic test allows visualization of the renal parenchyma and renal pelvis without exposure to external beam radiation or radioactive isotopes? a. Renal ultrasound b. Computed tomography c. Intravenous pyelography d. Voiding cystourethrography
Renal ultrasound
An inherited immunodeficiency disorder characterized by absence of both humoral and cell-mediated immunity is: a. Severe combined immunodeficiency syndrome (SCIDS). b. Acquired immunodeficiency syndrome. c. Wiskott-Aldrich syndrome. d. Fanconi syndrom
Severe combined immunodeficiency syndrome (SCIDS).
Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures? a. Avoiding hot beverages b. Shopping at an indoor mall c. Using a fan at low speed d. Walking slowly in the park
Shopping at an indoor mall
Which factor predisposes a child to urinary tract infections? a. Increased fluid intake b. Short urethra in young girls c. Prostatic secretions in males d. Frequent emptying of the bladder
Short urethra in young girls
Which immune preparation contains antibodies that provide passive immunity? 1 Toxoid 2 Killed vaccine 3 Live attenuated vaccine 4 Specific immune globulin
Specific immune globulin
The nurse is teaching parents of toddlers why children receiving specific medications should not receive varicella vaccines. Which medication would the nurse include in the discussion? 1 Insulin 2 Steroids 3 Antibiotics 4 Anticonvulsants
Steroids
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient how to dispose of tissues with respiratory secretions. b. Stock the patient's room with the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.
Stock the patient's room with the necessary personal protective equipment.
A client with ulcerative colitis has experienced frequent severe exacerbations over the past several years. The client is admitted to the hospital with intense pain, severe diarrhea, and cachexia. Which therapeutic course would the nurse expect the primary health care provider to explore with this client? 1 Intensive psychotherapy 2 Continued medical therapy 3 Surgical therapy (colectomy) 4 Diet therapy (low-residue, high-protein diet)
Surgical therapy (colectomy)
A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care? a. Teach the patient about the use of antifungal medications. b. Tell the patient to avoid tub baths until the symptoms resolve. c. Instruct the patient to refer recent sexual partners for treatment. d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).
Teach the patient about the use of antifungal medications.
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Which would the nurse consider teaching about how gamma globulin provides passive immunity? 1 It increases production of short-lived antibodies. 2 It accelerates antigen-antibody union at the hepatic sites. 3 The lymphatic system is stimulated to produce antibodies. 4 The antigen is neutralized by the antibodies that it supplies.
The antigen is neutralized by the antibodies that it supplies.
A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. Which information would the nurse include in the response? 1 Clients with this disease have an excellent prognosis with dietary changes. 2 The disorder affects males and females in equal numbers. 3 The disorder entails hypersensitivity, and the exact cause is unknown. 4 This disease affects only the kidneys and the retina of the eyes.
The disorder entails hypersensitivity, and the exact cause is unknown.
Which diagnostic test result indicates if a client will develop acquired immunodeficiency syndrome (AIDS) from the human immunodeficiency virus (HIV)? 1 Level of immunoglobulin M (IgM) in the client's blood 2 The number of CD4+ T cells available 3 Presence of antigen-antibody complexes 4 Speed with which the virus invades the ribonucleic acid (RNA)
The number of CD4+ T cells available
The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. Clear fluid is visible through the tympanic membrane. d. The patient frequently asks the nurse to repeat information.
The patient has a temperature of 100.6° F.
Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to require a change in medication? a. The patient has gained 3 lb. b. The patient has dark-colored stools. c. The patient's pain affects multiple joints. d. The patient uses capsaicin cream (Zostrix).
The patient has dark-colored stools.
The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient complains of feeling "constantly tired." b. The patient can't explain the effects of indinavir (Crixivan). c. The patient reports missing some doses of zidovudine (AZT). d. The patient reports having no side effects from the medications.
The patient reports missing some doses of zidovudine (AZT).
A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient uses witch hazel compresses to soothe irritation. c. The patient asks for antidiarrheal medication after each stool. d. The patient cleans the perianal area with soap after each stool.
The patient uses witch hazel compresses to soothe irritation.
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.
The patient will maintain intact perineal skin.
The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will begin sitting in a chair at the bedside on the first postoperative day. b. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria. c. An additional surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. The site where the stoma will be located will be marked on the abdomen preoperatively.
The site where the stoma will be located will be marked on the abdomen preoperatively.
A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.
This type of colostomy is usually temporary.
The nurse is assisting the pediatric provider with a newborn examination. The provider notes that the infant has hypospadias. The nurse understands that hypospadias refers to: a. Absence of a urethral opening. b. Penis shorter than usual for age. c. Urethral opening along dorsal surface of penis. d. Urethral opening along ventral surface of penis.
Urethral opening along ventral surface of penis.
The nurse prepares a male client with a history of recurrent urinary tract infections (UTIs) for discharge after a ureterolithotomy. Which clinical manifestations of a UTI would the nurse teach this client to recognize? 1 Urgency or frequency of urination 2 An increase of ketones in the urine 3 The inability to maintain an erection 4 Pain radiating to the external genitalia
Urgency or frequency of urination
Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.
Use care when eating high-fiber foods to avoid obstruction of the ileum.
Which factors may have led to the development of flexion contractures in a client with osteoarthritis (OA)? 1 Wearing shoes without insoles 2 Elevating the legs 8 to 12 inches 3 Using large pillows under the knees or head 4 Placing a small pillow under the head in the supine position
Using large pillows under the knees or head
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay
Viral load testing
A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI). Which urinalysis result should the nurse expect with these conditions? a. WBC <1; specific gravity 1.008 b. WBC <2; specific gravity 1.025 c. WBC >2; specific gravity 1.016 d. WBC >2; specific gravity 1.030
WBC >2; specific gravity 1.030
What should the nurse recommend to prevent urinary tract infections in young girls? a. Wearing cotton underpants b. Limiting bathing as much as possible c. Increasing fluids; decreasing salt intake d. Cleansing the perineum with water after voiding
Wearing cotton underpants
In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? a. Whether a patient has an infection. b. Where an infection is located. c. What cells are being utilized by the body to attack an infection. d. What specific type of pathogen is causing an infection.
What specific type of pathogen is causing an infection.
A client who is immunosuppressed is receiving filgrastim. When monitoring effectiveness, the nurse will check for an increase in which blood component? 1 Platelets 2 Erythrocytes 3 Lymphocytes 4 White blood cells
White blood cells
The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics? 1 Red blood cell count 2 Wound culture 3 Knee x-ray 4 Urinalysis
Wound culture
The recommended treatment for the prevention of human immunodeficiency virus (HIV) transmission to the fetus during pregnancy is: a. Acyclovir. b. Ofloxacin. c. Podophyllin. d. Zidovudine.
Zidovudine.
The nurse plans a presentation for community members about how to decrease the risk for antibiotic resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.
a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. Hand washing is effective in preventing many viral and bacterial infections.
On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient's wound. The nurse realizes what information about this fluid? a. Contains the materials used by the body in the initial inflammatory response. b. Indicates that the patient has an infection at the site of the wound. c. Is destroying healthy tissue. d. Results from ineffective cleansing of the wound area.
a. Contains the materials used by the body in the initial inflammatory response.
Examples of sexual risk behaviors associated with exposure to a sexually transmitted infection (STI) include (Select all that apply): a. Fellatio. b. Unprotected anal intercourse. c. Multiple sex partners. d. Dry kissing. e. Abstinence.
a. Fellatio. b. Unprotected anal intercourse. c. Multiple sex partners.
Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS) (Select all that apply)? a. Give supplemental vitamins as prescribed. b. Yearly influenza vaccination should be avoided. c. Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed. d. Notify the physician if the child develops a cough or congestion. e. Missed doses of antiretroviral medication do not need to be recorded.
a. Give supplemental vitamins as prescribed. c. Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed. d. Notify the physician if the child develops a cough or congestion.
The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin
a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine
The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation. a. Oral temperature 38.6° C/101.5° F b. Thick, green nasal discharge c. Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses d. WBC 20 cells/McL 109/L e. Patient reports, "I'm tired all the time. I haven't felt like myself in days."
a. Oral temperature 38.6° C/101.5° F d. WBC 20 cells/McL 109/L e. Patient reports, "I'm tired all the time. I haven't felt like myself in days."
Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition e. Mostly female gender
a. Uninsured or underinsured status c. High cost of medications d. Inadequate nutrition
The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations would be observed (Select all that apply)? a. Vomiting b. Jaundice c. Failure to gain weight d. Swelling of the face e. Back pain f. Persistent diaper rash
a. Vomiting c. Failure to gain weight f. Persistent diaper rash
A patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. b. fluid restriction. c. enteral nutrition. d. activity restrictions.
a. medication use.
A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily. a. 2 b. 3 c. 4 d. 5
a. 2
The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should a. avoid activities requiring repetitive use of the same muscles and joints. b. protect the knee joints by sleeping with a small pillow under the knees. c. stand rather than sit when performing daily household and yard chores. d. strengthen small hand muscles by wringing out sponges or washcloths.
avoid activities requiring repetitive use of the same muscles and joints.
The nurse will instruct a patient who has undergone a left tympanoplasty to a. remain on bed rest. b. keep the head elevated. c. avoid blowing the nose. d. irrigate the left ear canal.
avoid blowing the nose.
The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC)
b. Are part of primary prevention for system disorders d. Help protect individuals and communities f. Are recommended by the Centers for Disease Control and Prevention (CDC)
Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Stimulant and saline laxatives can be used regularly. b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation.
b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation.
According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection
b. Gown c. Gloves
The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a. Administration of protease inhibitors b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission d. Preventing visitors from entering the room e. Administration of intravenous fluids f. Strict monitoring of intake and output
b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission e. Administration of intravenous fluids f. Strict monitoring of intake and output
Which immunization should be given with caution to children infected with human immunodeficiency virus? a. Influenza b. Varicella c. Pneumococcus d. Inactivated poliovirus
b. Varicella
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup
c. Oatmeal with cream
The nurse should know that once human immunodeficiency virus (HIV) enters the body, seroconversion to HIV positivity usually occurs within: a. 6 to 10 days. b. 2 to 4 weeks. c. 6 to 8 weeks. d. 6 months.
c. 6 to 8 weeks.
The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. iron dextran infusions b. oral ferrous sulfate tablets. c. routine blood transfusions. d. cobalamin (B12) supplements.
cobalamin (B12) supplements.
A child with secondary enuresis who complains of dysuria or urgency should be evaluated for what condition (Select all that apply)? a. Hypocalciuria b. Nephrotic syndrome c. Glomerulonephritis d. Urinary tract infection (UTI) e. Diabetes mellitus
d. Urinary tract infection (UTI) e. Diabetes mellitus
A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient's oral food intake. c. administer cobalamin (vitamin B12) injections. d. teach the patient about total colectomy surgery.
discontinue the patient's oral food intake.
A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.
document stoma assessment findings.
A young adult male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of a. recent kidney trauma. b. gonococcal urethritis. c. recurrent bladder infection. d. benign prostatic hyperplasia.
gonococcal urethritis.
